Editorial

The Mid Staffordshire NHS Foundation Trust Public Inquiry finally published its report on 6 February 2013. The full response from the Government to the 290 recommendations by the chairman, Robert Francis QC, is not expected till the autumn of 2013. However, we got an idea of the main thrust of their reaction when the Secretary of State for Health, Jeremy Hunt, made an announcement to the House of Commons on 26 March. Bearing in mind that this was an exhaustive inquiry conducted over 18 months, concerning the biggest scandal ever to have affected the NHS, the Government's response was not only disappointing but quite worrying. The one exception was the U-turn in government policy, finally accepting the need for a statutory ‘duty of candour’ which some have described as the biggest advance in patients’ rights, and possibly in patient safety, in the history of the NHS. More on that later. However, while it would have been unrealistic to expect a line by line response to each recommendation, my and many other people's hopes were that there would at least be confirmation that the main drift of Francis's recommendations would be accepted, and that there would at the very least be a commitment to fully engage with all stakeholders over those recommendations over which the Government was less sure. Instead, some of the most fundamental recommendations were rejected and replaced with the Government's own ideas. Many others were simply ignored altogether.

One of Francis’ main conclusions was that the system of regulation needed to be strengthened and simplified so that there was less danger of different bodies leaving difficult issues to one side, claiming that it must be another organization's responsibility. This led him to make the unequivocal recommendation that there should be a single regulator – the Care Quality Commission (CQC) – responsible for setting, monitoring, and enforcing core standards of quality and safety. He warned in the strongest terms, against diluting the CQC's role. The Government's response is diametrically opposed to this approach. Instead, it proposes taking away the enforcement role of the CQC and leaving the responsibility for this ‘somewhere’ between a range of other bodies. Here is how Jeremy Hunt described it:

the CQC will no longer be responsible for putting right any problems identified in hospitals … . its job will simply be to identify problems, so it is not compromised in its ability to be the nation's whistleblower-in-chief. The responsibility for putting right problems will lie with Monitor, the NHS Trust Development Authority, the NHS Commissioning Board and the wider NHS system (Hansard, 26.03.13)

Other key areas where the Government seem to be set on taking a different course than that advocated by Robert Francis include his recommendations that healthcare assistants are formally regulated; that there is national guidance on minimum staffing levels for different healthcare settings; and that the patient's voice is strengthened by ensuring a consistent model for the new Healthwatch bodies and ring fencing their funding. Francis was struck by how various manifestations of patient and public involvement bodies created since the much lamented abolition of Community Health Councils (CHCs) had failed to get anywhere near being as good as CHCs. The same problems are being re-created with the Healthwatch bodies. Their funding is being handed to local authorities who have complete discretion as to whether they actually use it for Healthwatch or syphon it away to pay for other local authority responsibilities. This means that we will be left with a hotchpotch of local patient bodies all with different levels of funding and operating in inconsistent ways. In other words, they will be unlikely to be any better at spotting and raising concerns about problems like those at Stafford.

There will however be some good that comes from all of this. After years of rejecting repeated calls for introducing a legally binding, statutory ‘duty of candour’ on healthcare organizations (to be open and honest with patients/families about harm caused), the Government has finally given way. The strength of the campaign led by AvMA and the evidence presented to Francis, which led him to the unequivocal conclusion that this was what was needed, became irresistible. Some debate still continues about whether there will be a legal duty on individuals with potential criminal sanctions for breach of this duty. However, the corporate duty, if designed appropriately and enforced properly, should be robust and relate to everyone in a healthcare organization (including general practitioners). This would indeed be one of the biggest advances in patients’ rights and patient safety in the history of the NHS. For over 60 years the NHS has done no more than pay lip service to the fundamental principle that while it is human to err, to cover up is totally unacceptable. It is not only that denial of the truth following a medical accident is a gross injustice to the patients and families affected. The experience of Stafford and many other examples from around the country during AvMA's history tells us that an organization which tolerates cover-ups and unreasonable denial is going to be an unsafe organization. The devil will be in the detail and much work remains to be done to ensure that the statutory Duty of Candour is got right. Only then will it be worthy of the name kindly lent to our campaign by the Powell family: “Robbie's Law”.